by Randy A. Sansone, MD, and Lori A. Sansone, MDDr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (civilian) and Medical Director, Family Health Clinic, Wright-Patterson Medical Center in WPAFB, Ohio. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or position of the United States Air Force, Department of Defense, or US government.

Innov Clin Neurosci. 2012;9(4):22–16

This ongoing column is dedicated to the challenging clinical interface between psychiatry and primary care—two fields that are inexorably linked.

Funding: There was no funding for the development and writing of this article.

Financial Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Key words: Death, dying, grief, patient death, physician grief

Abstract: The genuine prevalence and intensity of grief reactions among physicians in response to patient death is unknown. However, a number of authorities and studies indicate that such experiences are fairly commonplace among physicians practicing in the clinical arena. In addition, it appears that the grief response of physicians may be tempered by a number of personal and environmental/contextual factors. A number of authors have proffered various approaches to resolving grief responses in these unique circumstances and many emphasize the importance of doing so in an effort to stave off burnout.

Introduction

At some point in their careers of medicine, most clinical physicians face the specter of patient death. However, despite this widespread professional phenomenon, the emotional experiences of physicians with regard to patient death have undergone limited investigation. Why is physician grief relevant? In addition to the foremost sense of loss, according to Redinbaugh, grief-related job stress may culminate in job-related burnout—a deleterious outcome that may affect up to 50 percent of physicians treating the terminally ill.[1] In this edition of The Interface, we review the sparse available research literature and fertile commentary over the past 20 years in the area of physician grief in relationship to patient death.

The Prevalence of Grief Responses in Physicians

While the explicit prevalence rate and symptom intensity of grief reactions in physicians due to patient death has never been fully studied, a number of investigators and authors have touched on various parts of the proverbial “elephant standing in the middle of the room,” and provided some piecemeal insights. For example, from an impressionistic perspective, Kasket stated that physicians often experience grief when faced with the death of a patient under their care.[2] Given this initial starting point, we will now review the limited prevalence studies on the grief phenomenon associated with patient death among trainees and physicians-in-practice.

Studies of primarily trainees. In a qualitative study from the United States, Rhodes-Kropf et al[3] interviewed 65 third-year medical students from two schools regarding their emotional reactions to patient deaths. In the final analysis, 32 interviews were examined. In this sample, 57 percent of respondents rated the effect of patient death as highly and emotionally impactful. As one might suspect, the finality of death and sudden death were the two items that evoked the strongest emotions from trainees. Interestingly, in those cases in which the patient was cared for by the student’s team, 63 percent indicated that there was no discussion by colleagues of the experience in the aftermath of the patient’s death.

The next two studies include both trainees and physicians-in-practice, although trainees appear to comprise the majority of participants. In the first, a study from the United States, Sullivan et al[4] explored the feelings and attitudes about patient deaths among medical students (n=1,455), residents (n=296), and faculty (n=287).[4] While the explicit frequency of bona fide grief responses among participants was not reported, nearly half felt unprepared to manage their emotions about patient deaths.

In a second study from the United States of 188 medical personnel (i.e., medical students, residents, and attending physicians) in two academic teaching institutions, Redinbaugh et al[5] examined participants’ reactions to the recent death of an “average patient.” While participants reported overall satisfying experiences in caring for dying patients, they also reported on a Likert-style rating scale moderate levels of emotional impact. Women participants and those physicians who had cared for the patient for a longer period of time experienced the strongest emotions. In the aftermath of the patient’s death, interns reported needing significantly more emotional support than attending physicians. Interestingly, although residents discussed the patient’s death with their attending physicians, less than a quarter found the experience to be helpful in terms of support.

Studies of physicians-in-practice. In a study from Scotland, Linklater surveyed 79 physicians about their experience with dying patients.[6] Respondents indicated that they were frequently exposed to patient deaths, but the authors again reported no explicit frequencies. In terms of their emotional experiences, 61 percent of respondents found their most memorable patient death to be emotionally distressing. Likewise, 26 percent reported recent personal bereavement due to a patient death.

Studies of crying on the job. While crying on the job may appear to be an unusual venue for exploration, there have been several studies of this behavior in trainees and physicians-in-practice, and investigators have consistently concluded that crying was most frequently related to patient death. For example, Angoff queried medical students about whether they had cried during a clinical rotation.[7] Of the 182 students, 73.1 percent reported crying and 16.5 percent reported near crying. When asked what specific clinical event had precipitated this emotional response, the majority stated that it was in response to the suffering and dying of a patient and/or the family’s associated distress.[7]

In an Australian study of medical personnel, Wagner et al[8] found that crying in hospitals was reported by 76 percent of nurses (n=103), 57 percent of physicians (n=52), and 31 percent of medical students (n=101).[8] As previously indicated, investigators found that the primary reason for participants’ on-the-job crying was identification and bonding with the suffering of dying patients and their families.

Finally, on-the-job crying was examined in an Austrian study by Barth and colleagues.[9] These investigators found that the emotional response of crying was fairly prevalent among the 275 medical personnel and medical students studied, and again most often occurred as an emotional reaction to dealing with dying patients.

Overall, findings indicate that a significant proportion of medical students and physicians-in-practice have experienced crying in response to patient dying or death. However, whether or to what degree crying behavior is predictive of an emerging grief response remains unknown.

Psychological Issues Related to Physician Grief with Dying Patients

Studies of trainees. Anderson et al10 examined graduating medical students with regard to their personal experience with a patient death. Among the 380 participants, 76 percent confirmed personal experiences with patient death, and participants generally reported a negative emotional experience to end-of-life care.[10]

In a Canadian study of medical students’ first experience with patient death, Kelly and Nisker[11] examined 29 students with interviews, focus groups, or e-mail interview. One pervasive theme among students was the tension between emotional concern for the patient and family and the intuited need for professional detachment. How this tension was negotiated was dependent upon the student’s clinical situation (e.g., supervisors’ response, support of supervisors and peers, opportunities for debriefing).

Studies of physicians-in-practice. One study has examined the emotional context of physicians-in-practice with regard to grief and dying patients. In this endeavor, McQuade[12] interviewed 25 physicians about their experiences with dying patients. The key psychological themes reported were grief and loss, uncertainty and lack of control, care versus cure, and issues of personal growth.

Other observed psychological themes. While not formal studies, a number of investigators have offered insights into physicians’ emotional responses to patient death. Rousseau[13] described the historic constraints of physicians in expressing emotion with and about patients for fear of allegedly contaminating clinical objectivity. Majhail and Warlick[14] affirmed the controversy around whether it is appropriate for physicians to display personal emotions in front of patients. In contrast, Siegel admonishes, “Please, fellow physicians, don’t cry in empty rooms, on stairwells, or in locker rooms—cry in public and let the patients and staff heal you and see you are human.”[15]

In keeping with this theme of suppressed emotion around patient death, in a Danish study, Vejlgaard and Addington-Hall[16] compared physicians and nurses who were working in palliative care. In this study of 347 participants, researchers found that physicians were more likely to leave the care of dying patients to others (avoidance?).

Finally, in a Hungarian study, Hegedus et al[17] examined 124 family physicians regarding their attitudes toward dying and death. In this study, researchers found that physician attitudes were generally negative toward the process and that participants tended to avoid communication with others about such matters.

Overall, the preceding material suggests a number of psychological themes around patient death, which are common among medical students, as well as physicians-in-practice. These themes center on uncomfortable feelings, grief, threatened control, and generally suppressed emotions. Why is it important to expose these themes? According to Pantilat and Isaac,[18] physicians must attend to these feelings to avoid burnout.

In additional to psychological factors, there appear to be a number of environmental or external contextual factors that affect how patient death is experienced by physicians. For example, in a Greek study of physicians and nurses providing care to children dying of cancer, Papadatou et al[19] found that the grieving process of these participants was affected by how they perceived their roles, the interventions given to the child, and the contribution of the participant to the care of the child.

In a study of internal medicine physicians, DelVecchio Good et al[20] examined the contextual themes associated with the recent death of a patient. In this qualitative analysis of 75 physicians, researchers found three major themes: 1) time and process (i.e., was the death expected or unexpected, peaceful or chaotic/prolonged?); 2) medical care and treatment decisions (i.e., was treatment rational and appropriate or futile and overly aggressive?); and 3) negotiation (i.e., was communication with the patient’s family effective or conflictual?). Again, findings indicate the importance of contextual factors in the tempering of emotional experiences of physicians as they process a patient’s death.

Finally, Jackson et al[21] examined the emotional experiences of physicians at two Boston hospitals regarding their most emotionally powerful patient death. Using semi-structured interviews, the investigators found that physicians reported “powerful deaths” at all points in their careers. The “power” in these deaths was usually attributed to one of three general themes: 1) a “good” death, 2) an “over-treated” death, and 3) a “shocking” or “unexpected” death.

Mastering Grief

Understandably, each physician has his or her own unique psychological composition, pre-existing existential belief structure, and experiences with death, suggesting that each will also have his or her own unique way of processing a patient-death experience. However, while the literature is sparse, several authors have offered suggestions for dealing with grief in this particular context. Moon suggests that physicians participate in death talks—social engagements that examine the complex dynamics of grief.[22] Other authors emphasize the importance of adequate professional grief support,[23] didactic preparation[24] such as end-of-life curricula in medical school settings,[25] death rounds (i.e., an end-of-life educational tool to address the emotional needs of trainees taking care of dying patients),[26] self-attunement or personal awareness (i.e., being attentive to personal needs, acknowledging feelings of grief and loss, pursuing healthy coping strategies),[27,28] the writing of clinical obituaries (i.e., drafting informal summaries of the benefits gained in the relationship with the patient in an effort to celebrate his or her life),[29] and the incorporation of humor.[30] There are probably other countless ways to address grief as well, and each professional must determine his or her most effective personal style for resolving patient loss.

Conclusion

At the present time, we do not know the genuine prevalence rate of physician grief reactions in response to patient death. However, the literature seems to affirm that this experience is fairly ubiquitous among clinicians. A number of psychological and contextual factors may temper the physician’s grief response, but again, studies are limited. While each physician likely has his or her own unique style of effectively dealing with grief, a number of authors have proffered suggestions for resolving grief reactions. The experience of patient death clearly affects a substantial proportion of clinicians, both in psychiatric and primary care settings. Effectively dealing with and resolving these painful losses will hopefully ease some of the emotional demands of clinical practice and curtail the risk of professional burnout.